Every day I experience life in the world of healthcare IT, supporting 3000 doctors, 18000 faculty, and 3 million patients. In this blog I record my experiences with infrastructure, applications, policies, management, and governance as well as muse on such topics such as reducing our carbon footprint, standardizing data in healthcare, and living life to its fullest.

Wednesday, May 31, 2017

What’s Next for Electronic Health Records?

With the Department of Justice announcement of the $155 million dollar eClinicalWorks settlement (including personal liability for the CEO, CMO and COO), many stakeholders are wondering what’s next for EHRs.

Clearly the industry is in a state of transition. eCW will be distracted by its 5 year corporate integrity agreement. AthenaHealth will have to focus on the activist investors at Elliott Management who now own 10% of the company and have a track record of changing management/preparing companies for sale. As mergers and acquisitions result in more enterprise solutions, Epic (and to some extent Cerner) will displace other vendors in large healthcare systems. However, the ongoing operational cost of these enterprise solutions will cause many to re-examine alternatives such as Meditech.

As an engineer, I select products and services based on requirements and not based on marketing materials, procurements by other local institutions, or the sentiment that “no one gets fired by buying vendor X”.

I have a sense that EHR requirements are changing and we’re in transition from EHR 1.0 to EHR 2.0. Here’s what I’m experiencing:

1. (Fewer government mandates) The era of prescriptive government regulation requiring specific EHR functionality is ending. In my conversations with government (executive branch, legislative branch), providers/payers, and academia, I’ve heard over and over that it is better to focus on results achieved than to do something like count the number the CCDA documents sent via the Direct protocol. If you want to use mobile devices to monitor patients in their homes - great! If you want to use telemedicine to do wellness checks - great! If you want to send off duty EMS workers using iPads to evaluate the activities of daily living for elderly patients - great! Reducing hospital readmissions is the goal and there are many enabling technologies. Suggesting that one size fits all in every geography for every patient no longer works as we move from a data recording focus (EHR 1.0) to an outcomes focus (EHR 2.0)

2. (Team-based care) Clinicians can no longer get through their day when the requirements are to see a patient every 15 minutes, enter 140 structured data elements, submit 40 quality measures, satisfy the patient, and never commit malpractice. A team of people is needed to maintain health and a new generation of communication tools is needed to support clinical groupware. This isn’t just HIPAA compliant messaging. We need workflow integration, rules based escalation of messages, and routing based on time of day/location/schedules/urgency/licensure. We need automated clinical documentation tools that record what each team member does and then requires a review/signoff by an accountable professional, not writing War and Peace from scratch until midnight (as is the current practice for many primary care clinicians)

3. (Value-based purchasing) Fee for service is dying and is being replaced by alternative quality contracts based on risk sharing.

Our electronic tools for EHR 2.0 should include the functionality necessary to document care plans, variation from those plans, and outcomes reported from patient generated healthcare data. Components of such software would include the elements that compromise the “Care Management Medical Record” - enrolling patients in protocols based on signs/symptoms/diagnosis, then using customer relationship management concepts to ensure patients receive the services recommended.

ICD-10, CPT, and HCPCS would no longer be necessary. Bills will no longer be generated. Payments would be fixed per patient per year and all care team members would be judged on wellness achieved for total medical expense incurred. SNOMED-CT would be the vocabulary used to record clinical observations for quality measurement.

4. (Usability) I do not fault EHR developers for the lack of usability in medical software. They were given thousands of pages of regulations then told to author new software, certify it, and deploy it in 18 months. I call this the “ask 9 women to have a baby in 1 month” concept, since Meaningful Use timeframes violated the “gestation period” for innovation. How can we achieve better usability in the future? My view is that EHRs are platforms (think iPhone) and legions of entrepreneurs creating add on functionality author the apps that run on that platform. Every week, I work with young people creating the next generation of highly usable clinical functionality that improves usability. They need to be empowered to get/put data from EHR platforms and emerging FHIR standards will help with that.

I was recently asked to define HIT innovation. I said it was the novel application of people, processes and technologies to improve quality, safety and efficiency. Creating modules that layer on top of existing EHR transactional systems embraces this definition.

5. (Consumer driven) In a recent keynote, I joked that my medical school training (30 years ago) in customer service mirrored that provided by the US domestic airlines. Healthcare experiences can be like boarding a crowded aircraft where your presence is considered an inconvenience to the staff. We’re entering a new era with evolving models that are moving care to the home including internet of things monitoring, supporting convenient ambulatory locations near you, offering urgent care clinics with long hours, enabling electronic self scheduling, and encouraging virtual visits. Although existing EHR 1.0 products have patient portals, they have not made the patient/family an equal member of the care team, providing them with care navigation tools. BIDMC is working on an Amazon Echo/Alexa service backed by microservices/Bots that brings ambient listening technologies to the home for coordination with care teams. When see you articles like this one, you know that the technology tools we have to support patients as consumers are not yet sufficient.

The US has been working on EHR 1.0 for a long time. 57 years ago, the New England Deaconess computerized its pharmacy using an IBM Mainframe. Here’s the original document from 1960 describing the achievement. Of note, the document highlights that the overall hospital budget reached a new high - $5.4 million and the increased salary, clinical care and IT expense meant that hospital rates would have to be raised to $25/bed/day. After nearly six decades of work on EHR 1.0, let’s declare victory and move onto social networking-like groupware supporting teams of caregivers focused on value while treating patients as customers using mobile and ambient listening tools. Government and private payers need to align incentives to support this future based on outcomes, putting the era of prescriptive EHR 1.0 functionality (and the energy enforcing the regulations) behind us.

3 comments:

Terrific post on a really interesting topic! I agree with your points, but if I had to take a flight of fancy for predicting the directions of a truly next-generation EHR, I would see it going something like this:

Physician data entry into the EHR UI will cease to be the center of data collection about the patient, instead patient data will be imported from a variety of sources and physicians will interact directly and naturally with whatever device, instrument or application they happen to be using; these devices will be mobile, connected and cloud-based. Care collaboration between providers and prompts for data-driven successful pathways (i.e. artificial intelligence) will also happen directly at the device in a natural way at the point of care. This is already starting to happen in ophthalmology.

Sources for patient data will expand beyond provider-entered data and lab results to include home monitoring, patient-reported outcomes, app data, iOT data, compliance data and so on. The EHR will fade into the background but will continue to be at the center of patient records for the health system - the place where all patient data is collected, stored and interoperability provided.

This leads to a separation of data, workflows and user interface which will be unbundled. CIO magazine had an article on this topic: http://www.cio.com/article/3185388/ehr/the-next-generation-of-ehrs-will-be-fundamentally-different.html .

2017 is the year of the national patient identifier discussion. GAO will be doing a cost/benefit analysis of the national patient identifier as required by the 21st Century Cures legislation. The Pew Charitable Trust is convening a multi-stakeholder group this Summer to prioritize recommendations. I'm hopeful we'll have a path forward soon.